Physicians' Academy for Cardiovascular Education

Evidence suggests proton-pump inhibitor can lower risk of severe GI bleeding in the elderly on antiplatelet therapy

Age-specific risks, severity, time course, and outcome of bleeding on long-term antiplatelet treatment after vascular events: a population-based cohort study

Li L, Geraghty OC, Mehta Z, et al. - Lancet 2017; published online ahead of print


Guidelines on the secondary prevention of vascular events recommend the lifelong use of daily aspirin or other antiplatelet drugs, but they do not include any recommendations on proton-pump inhibitor (PPI) use, for the reduction of major bleeding risk in high-risk patients [1,2]. PPIs are not routinely prescribed in these patients, and the definitions of high risk in this case vary [3,4]. Relevant studies included mainly patients younger than 75 years, in primary prevention settings with a relatively short follow-up [5,6].

In this population-based cohort study, the age-specific risks, site, severity, outcomes, time course, and predictors of bleeding complications in secondary prevention of vascular events were determined, in order to estimate the potential effect of routine PPI use on reducing bleeding.

For this purpose, 3166 patients in the Oxford Vascular Study with a first acute TIA, ischemic stroke, or MI, who were treated with aspirin-based antiplatelet drugs in secondary prevention, but did not receive routine PPI treatment, were followed-up from 2002 until 2013. Patients on oral anticoagulants and patients with contraindications for antiplatelet therapy were not included in the study. Bleedings were considered to be disabling, if they resulted in a deterioration in functional independence (modified Rankin Scale increased to ≥3, or increased by ≥1 point if premorbid modified Rankin Scale ≥3) at hospital discharge without recovery by the next follow-up visit.

Main results


In patients on secondary prevention for ischemic events, receiving antiplatelet therapy without routine PPI use, the long-term risk of bleeding at age 75 years or older is higher and more sustained compared with younger age groups, with particularly high risks of disabling or fatal upper GI bleeding. The estimated NNT for routine PPI use to prevent major upper GI bleed is low and co-prescription should be considered in future secondary prevention guidelines.


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Find this article online at The Lancet